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Doi 10 5830 Cvja 2019 051
Doi 10 5830 Cvja 2019 051
Cardiovascular Topics
Enrollment
AE
Evaluation ABPM
Rest of 48 h
cardiopulmonary test 24 h
LE
75% RHR
50 minutes
Aquatic
environment
AE-PEH
3 BP 5 minutes: preparatory activity
Evaluation measures 20 minutes: aerobic exercise ABPM
cardiopulmonary test before exercise 20 minutes: resistance exercise 24 h
RHR 5 minutes: stretching exercise
LE-PEH
75% HRR
50 minutes
land
environment
Fig. 1. Study design. RHR: reserve heart rate; ABPM: ambulatory blood pressure measurement.
AFRICA CARDIOVASCULAR JOURNAL OF AFRICA • Advance Online Publication, October 2019 3
Table 1. General profile of the two hypertensive groups Table 2. Cardiovascular response to maximal effort in
the cardiopulmonary test in hypertensive subjects
LE-PEH AE-PEH LE AE
trained in aquatic and land exercise
(n = 10) (n = 10) (n = 10) (n = 10)
Age (years) 67 ± 3 64 ± 3 65 ± 3 70 ± 2 AE (n = 10) LE (n = 10)
BMI (kg/m²) 26.4 ± 3.4 25.7 ± 2.8 27.3 ± 3.3 26.5 ± 5.2 HR (bpm) 134 (124.9–143.9) 147 (136.5–157.3)*
Peak Vo2 (ml/kg/min) 23.4 ± 3.4 22.6 ± 2.1 25.7 ± 4.7 24.8 ± 3.4 SBP (mmHg) 160 (150.9–191.7) 162.5 (151.3–177.9)
Resting SBP (mmHg) 140 ± 4.4 153 ± 5.0 130 ± 8.3 128 ± 9.8 DBP (mmHg) 80.0 (72.4–89.6) 90.0 (84.1–90.5)*
AE: aquatic exercise; LE: land exercise; HR: heart rate; SBP: systolic blood
Resting DBP (mmHg) 85 ± 4.3 90 ± 5.6 82 ± 4.2 81 ± 8.1
pressure; DBP: diastolic blood pressure. *p < 0.05 when compared to AE.
Antihypertensive drugs (n) 2 (1–2) 1 (1–2) 2 (2–3) 1 (1–2) Mann–Whitney test, data expressed in median and 95% confidence interval.
Diuretic (%) 60 50 60 50
ACE inhibitor (%) 20 0 20 0
ARB (%) 80 80 60 80
measurement made every 15 minutes during the periods of
AE-PEH: aquatic exercise PEH; LE-PEH: land exercise PEH; AE: aquatic the day when the individual was awake (07:00 to 23:00), and
exercise; LE: land exercise; PEH: post-exercise hypotension; VO2; volume of the sleep period, during which the BP was measured every 30
oxygen; BMI: body mass index; SBP: systolic blood pressure; DBP: diastolic
blood pressure; ACE inhibitor: angiotensin converting enzyme inhibitor; ARB:
minutes and the mean value taken when the individual was
angiotensin II receptor blocker. Data expressed as mean ± SD. asleep (23:00 to 07:00). The result for each hour was then the
average of the values recorded during that hour.
individuals enrolled in regular AE (n = 20), of whom the arterial For the AE-PEH, each individual remained at rest in a seated
baseline pressures of 10 were evaluated for 24 hours after 48 position for 15 minutes, then BP was measured three times with
hours of rest after their last exercise training; and in the other 10 a sphygmomanometer and stethoscope. Subsequently the test
subjects the PEH induced by an AE session was assessed. The exercise session was started, which consisted of collective water
other 20 individuals enrolled in regular LE were randomised and aerobics with a duration of 50 minutes, comprising five minutes
evaluated in the same way (Fig. 1). of preparatory activity, 20 minutes of aerobic exercises at 75%
Body mass was measured with a digital scale having a capacity of reserve HR (RHR), 20 minutes of strength exercises, and five
of 150 kg and an accuracy of 100 g (EKS® SUPER 9805). Height minutes of stretching. The HR was monitored by a heart rate
measurement was performed with a compact stadiometer fixed monitor (POLAR® RS800) during the entire session. After the
to the wall, and with a range of 0 to 2.0 m and an accuracy of experimental session, ABPM was used to record BP during the
1 mm (Coats Corrente® BA1010). following 24-hour period.
The heart rate (HR) was measured in both groups at rest and For the LE-PEH, each individual remained at rest in a seated
after a cardiopulmonary test. For this a cardiac monitor (Polar® position for 15 minutes, then the BP was measured three times
model FT1) was used to collect resting HR. The HR recording with a sphygmomanometer and stethoscope. Subsequently the
was made in the seated position for two minutes after a rest of test exercise session was started, which consisted of aerobic
10 minutes; the lowest HR reached in this period was used. The collective gymnastics with a duration of 50 minutes, including
maximal HR was measured immediately after completion of the five minutes of preparatory activity, 20 minutes of aerobic
cardiopulmonary test. exercises at 75% of RHR, 20 minutes of resistance exercises,
For evaluation of the maximum aerobic capacity (VO2 max), the and five minutes of stretching. HR was monitored by a heart
progressive treadmill test was applied following the Balke–Ware rate monitor (POLAR® RS800). After the experimental session,
protocol.34 The maximal VO2 was evaluated using an open- ABPM was used to record the BP during the following 24-hour
circuit spirometry VO2000® ventilometer and an Inbramed® period.
treadmill.35,36
BP was measured at rest and after cardiopulmonary tests in
both groups. For the former, the BP was assessed three times Statistical analysis
after 10 minutes of rest in a seated position at intervals of one The Shapiro–Wilk test was used to evaluate the normality of
minute, and the result was taken as the mean value, while for the numerical data. Data are presented as mean ± standard
the latter, the BP was assessed immediately after completion of deviation. An unpaired t-test with Welch’s correction was used
the treadmill test with a stethoscope (Missouri®) and a manual to compare the cardiopulmonary response between AE and LE,
aneroid sphygmomanometer (Missouri®) with a precision of as well as the magnitude of PEH at the second, 12th and 24th
2 mmHg. hours after the session.
The ABPM was started 48 hours after the last training Two-way ANOVA was used to compare PEH for the sessions
session to evaluate the baseline BP in the AE and LE groups. by time (second, 12th and 24th hour), as well as determine
To evaluate PEH, the ABPM was started immediately after interaction effects (session and time), followed by Bonferroni’s
the exercise session. Three devices of the Meditech KFT® post hoc test. A 5% significance level was set. All statistical
brand, model ABPM-04, were used. The BP cuff was worn on analyses utilised Graph Pad Prism 7.0
the non-dominant arm. Subjects were instructed to maintain
their customary daily activities, not to exercise, and to relax
and unbend the arm during the recording interval for daytime
Results
ABPM. ABPM data were accepted with more than 75% of the Table 1 shows the characteristics of the experimental groups.
measurements effectively taken. Individual BP measurements There were no differences between the groups by age, body mass
were revised for missing and erroneous values. index, peak VO2, or resting systolic BP (SBP) and DBP.
For comparison purposes, data were distributed across Table 2 shows the HR and BP responses to maximal effort
the waking period, which consisted of the mean BP of the recorded after the cardiopulmonary test. The values of HR and
4 CARDIOVASCULAR JOURNAL OF AFRICA • Advance Online Publication, October 2019 AFRICA
A
140 * 140 140 &
135 135 135
130 130 130
125 125 125
mmHg
mmHg
mmHg
60 60 60
40 40 40
20 20 20
0 0 0
AE LE AE LE AE LE
SBP daytime SBP night-time SBP 24-h average
B
80 80 80
#
75 75
75
70 70
70
65 65
mmHg
mmHg
mmHg
65 60 60
40 40
30 30 40
20 20
20
10 10
0 0 0
AE LE AE LE AE LE
DBP daytime DBP night-time DBP 24-h average
Fig. 2. A
verage SPB (A) and DBP (B) during the daytime, night-time, and over 24 hours. AE: aquatic exercise; LE: land exercise
*p < 0.0001 when compared with AE, SPB daytime (AE 124 ± 4 mmHg, LE 134 ± 6 mmHg) ; #p < 0.0001 when compared
with AE, DPB daytime (AE 70 ± 3 mmHg vs LE 76 ± 4 mmHg); &p < 0.02 when compared with AE, SPB 24 hours (AE 121
± 5 mmHg vs LE 125 ± 10 mmHg)
DBP were significantly higher in the LE than the AE group, but mmHg) and DBP (70 ± 3 mmHg) than the LE group (SBP: 134 ±
there were no differences observed in SBP. 6 mmHg, DBP: 76 ± 4 mmHg), as well as for the 24-hour average
Fig. 2 shows the values of SBP (A) and DBP (B) during the for SBP (AE: 121 ± 5 mmHg vs LE: 125 ± 10 mmHg). There was
daytime, night-time and total 24 hours (daytime plus night-time). no difference between the groups during the night-time or for the
The AE group showed lower values for daytime SBP (124 ± 4 24-hour average of DBP.
A B
180 100
170
90 a a,*
160
150 a a,b a,b
a 80
mmHg
mmHg
140
130 70
120
60
110
100 50
0-h 2-h 12-h 24-h 0-h 2-h 12-h 24-h
SBP PEH DBP PEH
AE-PEH LE-PEH AE-PEH LE-PEH
Fig. 3. S
BP (A) and DBP (B) PEH in the AE and LE groups at the second-, 12th- and 24th-hour time points. a: represents the
difference between AE-PEH baseline and the time points, b: represents the difference between LE-PEH baseline and the
time points, *represents the difference between the groups at the same time point. a: p < 0.001 when compared to AE-PEH
at 0 hours (SBP/DBP AE-PEH: baseline (0 h) 155 ± 7/90 ± 4 mmHg, second hour 133 ± 15/76 ± 11 mmHg, 12th hour 129 ±
19/69 ± 11 mmHg, 24th hour 123 ± 14/66 ± 9 mmHg); b: p < 0.03 when compared to LE-PEH at 0 hours (SBP/DPB LE-PEH:
baseline (0 h) 139 ± 5/85 ± 2 mmHg, 12th hour 122 ± 9/71 ± 8 mmHg); *p < 0.01 when compared with LE-PEH (DBP AE-PEH
66 ± 9 mmHg, LE-PEH 80 ± 7 mmHg). AE: aquatic exercise; LE: land exercise; PEH: post-exercise hypotension. Two-way
ANOVA with Bonferroni correction, data expressed as mean ± SD. Interaction for SBP: p = 0.0544, DBP: p = 0.0099.
AFRICA CARDIOVASCULAR JOURNAL OF AFRICA • Advance Online Publication, October 2019 5
A
0 0 0
–10 –10
–10
–20 –20
mmHg
mmHg
mmHg
–20
–30 –30
–30
–40 –40
#
–40 –50 –50
AE-PEH 2-h LE-PEH 2-h AE-PEH 12-h LE-PEH 12-h AE-PEH 12-h LE-PEH 12-h
SBP PEH SBP PEH SBP PEH
B
0 0 0
–10 –10
–10
mmHg
mmHg
mmHg
–20 –20
–20
–30 –30
*
Fig. 4. M
agnitude of PEH in the exercise groups AE-PEH and LE-PEH for SBP (A) and DBP (B) at the second, 12th and 24th
hour. PEH: post-exercise hypotension. #p < 0.001 when compared with LE-PEH 24th hour (SBP AE-PEH –31 ± 10 mmHg vs
LE-PEH –10 ± 10 mmHg); *p < 0.01 when compared with LE-PEH 24th hour (DBP AE-PEH –23 ± 9 mmHg vs LE-PEH –10
± 8 mmHg). Unpaired t-test with Welch’s correction, data expressed as mean ± SD.
Fig. 3 shows the PEH for SBP (A) and DBP (B) in the Both training environments have been shown to be efficacious
AE-PEH and LE-PEH groups at the second, 12th and 24th in reducing BP, but aquatic training caused a more impressive
hours after the exercise session, those times being chosen because reduction (−10.58 mmHg) than that due to land aerobic
the individuals were then awake. The AE-PEH data show that training (−3.5 mmHg) or resistance training (−1.8 mmHg).3
PEH was maintained from the second to the 24th hour, while The baseline data show that AE induced lower BP values, an
for the LE group, maintenance of PEH was observed only until effect appearing during the awake period, which could be due to
the 12th hour. There was no difference in PEH at the second higher sympathetic tonus activity during the awake period than
and 12th hour between the groups, but for DBP, at the 24th at night, as data show that in the daytime there is a prevalence
hour, AE-PEH values were lower (66 ± 9 mmHg) than those of of sympathetic tonus.37
LE-PEH (80 ± 7 mmHg). AE modulates the sympathetic drive differently from that
Fig. 4 shows SBP (A) and DBP (B) for the groups AE-PEH observed for LE. In AE, one should consider the effect of
and LE-PEH. There was no difference in PEH at the second hydrostatic pressure, which induces an increase in blood
and 12th hours between the groups, but the 24th hour PEH was concentration in the thorax38 and reflexively decreases the heart
higher for the AE group (SBP: −31 ± 11 mmHg, DBP: −23 ± 8 rate. Increased venous return during immersion stimulates
mmHg) than for the LE group (SBP: −10 ± 10 mmHg, DBP: cardiopulmonary receptors, which decrease sympathetic activity
−10 ± 8 mmHg). and total peripheral resistance.39 Bradycardia also occurs
during immersion.40 In addition, data reported in the literature
show that aquatic-based exercise induces a different response
Discussion associated with renal sympathetic nerve activity,23 as well as
The main finding of this study was that elderly hypertensive higher suppression of the vasopressin and renin–angiotensin
subjects trained in AE had different baseline BP responses systems, from that of physical activities on land.41,42
from land-trained subjects. During the daytime, SBP and DBP The maximal response to the cardiopulmonary test shows
values were lower for aquatic-trained hypertensive subjects. In that both groups had the same VO2 max, but, interestingly,
addition, the PEH induced by AE was more rapid and lasted hypertensives trained in AE had lower HR and DBP during
longer than that induced by LE, based on data recorded 24 hours maximal effort. The chronic effect of AE ameliorates arterial
after the exercise session. Another interesting result was the peripheral resistance, and the decrease in levels of epinephrine,
cardiovascular response after a cardiopulmonary test: maximal norepinephrine and endothelin-1 associated with an increase in
HR and DBP were higher for land-trained than aquatic-trained nitric oxide levels can improve the BP response during exercise,
subjects. including DBP.43 We found that elderly hypertensive subjects had
6 CARDIOVASCULAR JOURNAL OF AFRICA • Advance Online Publication, October 2019 AFRICA
a better profile of cardiovascular responses during AE. The DBP ment of 79 behavioural, environmental and occupational, and metabolic
decreases during aquatic cycle ergometer exercise were greater risks or clusters of risks, 1990–2015: a systematic analysis for the Global
than in the case of the same exercise intensity on land.44 Burden of Disease Study 2015. Lancet 2016; 388(10053):1659–1724.
Our data show that PEH for SBP and DBP lasted for 24 3. Cornelissen VA, Smart NA. Exercise training for blood pressure: a
hours after AE, which was longer than for LE. Similarly, systematic review and meta-analysis. J Am Heart Assoc 2013; 2(1):
Ngomane30 showed that heated AE was more effective in e004473.
producing PEH for 11–18 hours after a bout of exercise than 4. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ,
LE. The higher PEH after AE was observed in reduced SBP Lee I-M, et al. Quantity and quality of exercise for developing and
and DBP during the daytime, but there was no difference found maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness
in any other haemodynamic variable assessed: arterial stiffness, in apparently healthy adults: guidance for prescribing exercise. Med Sci
endothelial reactivity or heart rate variability. Our findings Sports Exerc 2011; 43(7): 1334–1359.
likewise corroborate the results of Bocalini,45 who verified that 5. Johnson HM, Olson AG, LaMantia JN, Kind AJ, Pandhi N, Mendonça
water ergometric exercise was effective in promoting a higher EA, et al. Documented lifestyle education among young adults with
magnitude of PEH in older hypertensive women with more incident hypertension. J Gen Int Med 2015; 30(5): 556–564.
apparent outcomes in untreated women, than LE. 6. Pescatello LS, MacDonald HV, Lamberti L, Johnson BTJC. Exercise
Concerning the mechanisms associated with PEH, several for hypertension: a prescription update integrating existing recommen-
have been presented in the literature as playing a major role dations with emerging research. Curr Hypertens Rep 2015; 17(11): 87.
in these effects on BP: reduction in sympathetic activity,46 7. Moraes-Silva IC, Mostarda CT, Silva-Filho AC, Irigoyen MC.
attenuation of cardiac adrenergic receptor sensitivity, decreased Hypertension and exercise training: evidence from clinical studies.
catecholamine synthesis with changes in renin and angiotensin Exercise for Cardiovascular Disease Prevention and Treatment. Springer,
release as a result,47 lesser peripheral vascular resistance48 and 2017: 65–84.
stroke volume,49 and synthesis of vasopressin21 and endothelins.50 8. Bertani RF, Campos GO, Perseguin DM, Bonardi JMT, Ferriolli E,
The mechanism whereby AE creates lasting PEH however needs Moriguti JC, et al. Resistance Exercise training is more effective than
better elucidation. interval aerobic training in reducing blood pressure during sleep in hyper-
Our study used a session of combined aerobic and resistance tensive elderly patients. J Strength Cond Res 2018; 32(7): 2085–2090.
exercises for AE, and PEH was longer and started earlier (two 9. Cavalcante PAM, Rica RL, Evangelista AL, Serra AJ, Figueira Jr A,
hours after the exercise session) than for LE. This result is in Pontes Jr FL, et al. Effects of exercise intensity on postexercise hypoten-
agreement with Ferrari,51 who used concurrent training, aerobic sion after resistance training session in overweight hypertensive patients.
plus resistance training, to show a reduction in BP in the first Clin Interv Aging 2015; 10: 1487.
hour after training in hypertensive subjects participating in LE, 10. De Freitas Brito A, do Socorro Brasileiro-Santos M, de Oliveira
but such an effect may not last as long as that of aerobic exercise CVC, da Cruz Santos AJTJoS, Research C. Postexercise hypotension
alone. Similarly, Cunha32 found that moderate-intensity AE is volume-dependent in hypertensives: autonomic and forearm blood
elicited PEH for SBP and DBP for over 21 hours. Pinto52 assessed responses. J Strength Cond Res 2019; 33(1): 234–241.
the effect of concurrent training in water on normotensive 11. Imazu AA, Goessler KF, Casonatto J, Polito MDJB. The influence of
subjects to show a similar effect on PEH from resistance and physical training status on postexercise hypotension in patients with
aerobic exercise. hypertension: a cross-sectional study. Blood Press Monit 2017; 22(4):
196–201.
12. Keese F, Farinatti P, Pescatello L, Monteiro WJT. A comparison of
Conclusion the immediate effects of resistance, aerobic, and concurrent exercise on
Our study shows that elderly hypertensive individuals who postexercise hypotension. J Strength Cond Res 2011; 25(5): 1429–1436.
exercised in water had lower SBP and DBP during the day than 13. Keese F, Farinatti P, Pescatello L, Cunha F, Monteiro WJI. Aerobic
those trained in land exercise. In addition, hypotension was exercise intensity influences hypotension following concurrent exercise
induced more quickly (two hours) by the exercise session after sessions. Int J Sports Med 2012; 33(02): 148–153.
water-based exercise and lasted longer (24 hours) than that 14. De Freitas Brito A, de Oliveira CVC, do Socorro Brasileiro-Santos M,
induced by land-based exercise. These data show that water- da Cruz Santos AJC. Resistance exercise with different volumes: blood
based exercise has a different pressure control than land-based pressure response and forearm blood flow in the hypertensive elderly.
exercise, such that water-based exercise constitutes a potential Clin Interv Aging 2014; 9: 2151.
clinical approach for the treatment of hypertension. 15. Silva LE, Valim V, Pessanha APC, Oliveira LM, Myamoto S, Jones
A, et al. Hydrotherapy versus conventional land-based exercise for the
This study was supported by the Pro-Rectory of Research and Postgraduate management of patients with osteoarthritis of the knee: a randomized
of the Federal University of Ouro Preto (PROPP-UFOP). clinical trial. Phys Ther 2008; 88(1): 12–21.
16. Suomi R, Collier DJA. Effects of arthritis exercise programs on func-
tional fitness and perceived activities of daily living measures in older
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